Mini-CAT

Matt Lemieszewski
PA Portfolio II – Summer 2022
Mini-CAT

Clinical Scenario:
A patient is being transferred to your subacute rehab facility from a local hospital following bilateral ORIF on the tibias. While completing your initial provider assessment, your attending starts them on Omeprazole 20mg QD prophylaxis despite any clinical indications or history of GERD or PUD.

Search Question:
Does the long-term use of a proton pump inhibitor as prophylaxis actually prevent the occurrence of PUD or upper GI bleeds?

PICO Table:

PopulationInterventionComparisonOutcome(s)
Geriatric patientsProton pump inhibitorsNo treatmentIncidence of ulcers
SNF residentsPPIsPlaceboIncidence of GI bleed
Subacute rehab patientsOmeprazole Rebound acid hypersecretion
Critically ill patients‘-azole’ Increased infection rates
ICU patients   

Search Strategy and Databases Used:

  • PubMed:
    • PPI Overuse: 7
    • PPI prophylaxis and GI Bleed: 4
    • Proton pump inhibitors AND stress ulcer prophylaxis: 32

  • JAMA:
    • PPI prophylaxis and GI Bleed: 2
    • Stress ulcer prophylaxis and proton pump inhibitors: 1

  • NEJM:
    • Stress ulcer prophylaxis and proton pump inhibitors: 9
    • PPI prophylaxis adverse effects: 2

  • Science Direct:
    • Proton pump inhibitors AND stress ulcer prophylaxis: 91
    • PPI prophylaxis causing ulcers: 66

I narrowed down the initial list of of articles by choosing the studies that were most relevant to my clinical scenario and question. Because my search question included both patient prognosis and potential harms, I screened for articles that were either meta-analyses, systematic reviews, randomized control trials, and cohort studies if neither of the first two were available. A randomized controlled trial (RCT) can give evidence of efficacy and efficiency while minimizing or eliminating bias. A major advantage of the cohort study design is the ability to study multiple outcomes that can be associated with a single exposure or multiple exposures in a single study. Even the combined effect of multiple exposures on the outcome can be determined.

Research Used:

CitationVilcu, Ana-Maria, et al. “Association between Acute Gastroenteritis and Continuous Use of Proton Pump Inhibitors during Winter Periods of Highest Circulation of Enteric Viruses.” JAMA Network Open, vol. 2, no. 11, 2019, https://doi.org/10.1001/jamanetworkopen.2019.16205.
AbstractIMPORTANCE: An increased risk of acute bacterial enteric infections has been reported among patients receiving proton pump inhibitor (PPI) therapy. The risk of acute gastroenteritis (AGE) of viral origin associated with continuous PPI exposure has been less studied.   OBJECTIVE: To investigate the association between continuous PPI therapy and AGE occurrence during winter epidemic periods when the circulation of enteric viruses is the highest.   DESIGN, SETTING, AND PARTICIPANTS: A matched cohort study was performed using a prospectively collected drug dispensing database from a large panel of community pharmacies in continental France. All patients recorded in the database during the 2015 to 2016 winter season, with documented age, sex, and use of an identifiable regular panel pharmacy, were eligible for the study. Each patient exposed to continuous PPI therapy was matched to 3 unexposed patients, according to year of birth, sex, and identifiable regular panel pharmacy. Analyses were performed between January 2017 and December 2018.   EXPOSURE: Continuous PPI use during the 2015 to 2016 AGE winter epidemic.   MAIN OUTCOMES AND MEASURES: The occurrence of at least 1 AGE episode during the 2015 to 2016 AGE winter epidemic was the main outcome. Episodes of AGE were identified using a previously validated algorithm based on drug dispensing data. Relative risks of AGE were estimated using a multivariable log-binomial model adjusted for age, sex, and treatments for chronic conditions.   RESULTS: There were 233 596 patients receiving PPI therapy (median [interquartile range] age, 71 [62-81] years; 55.8% female) and 626 887 matched patients not receiving PPI therapy (median [interquartile range] age, 70 [61-80] years; 56.3%female) included in the analyses. At least 1 AGE epidemic episode was identified in 3131 patients (1.3%) receiving PPI therapy and in 4327 patients (0.7%) not receiving PPI therapy. The adjusted relative risk of AGE for those receiving PPI therapy was 1.81 (95%CI, 1.72-1.90) for all ages considered, 1.66 (95%CI, 1.54-1.80) among those aged 45 to 64 years, 2.19 (95%CI, 1.98-2.42) among those aged 65 to 74 years, and 1.98 (95%CI, 1.82-2.15) among those aged 75 years and older.   CONCLUSIONS AND RELEVANCE: Continuous PPI therapy was associated with an increased risk of developing AGE during periods of highest circulation of enteric viruses. These findings support the hypothesis that PPI use is associated with an increased risk of enteric viral infections.
Link:https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755852
CitationOrelio, Claudia C., et al. “Reducing Inappropriate Proton Pump Inhibitors Use for Stress Ulcer Prophylaxis in Hospitalized Patients: Systematic Review of De-Implementation Studies.” Journal of General Internal Medicine, 2 Feb. 2021, https://doi.org/10.1007/s11606-020-06425-6.
AbstractBackground A large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients.   Methods We searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use.   Results We included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03–0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18–0.26 to RR 0.76; 95% CI 0.68–0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies.   Discussion All identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.
Link:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298652/
CitationAlhazzani, Waleed, et al. “Efficacy and Safety of Stress Ulcer Prophylaxis in Critically Ill Patients: A Network Meta-Analysis of Randomized Trials.” Intensive Care Medicine, vol. 44, no. 1, 4 Dec. 2017, pp. 1–11., https://doi.org/10.1007/s00134-017-5005-8.
AbstractPurpose Stress ulcer prophylaxis (SUP) is commonly prescribed in the intensive care unit. However, data from systematic reviews and conventional meta-analyses are limited by imprecision and restricted to direct comparisons. We conducted a network meta-analysis of randomized clinical trials (RCTs) to examine the safety and efficacy of drugs available for SUP in critically ill patients.   Methods We searched MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2017 for randomized controlled trials that examined the efficacy and safety of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP in critically ill patients. No date or language restrictions were applied. Data on study characteristics, methods, outcomes, and risk of bias were abstracted by two reviewers.   Results Of 96 potentially eligible studies, we included 57 trials enrolling 7293 patients. The results showed that PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence). There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality). Mortality is probably similar across interventions (moderate quality). Estimates of baseline risks of bleeding varied significantly across studies, and only one study reported on Clostridium difficile infection. Definitions of pneumonia varied considerably. Most studies on sucralfate predate pneumonia prevention strategies.   Conclusions Our results provide moderate quality evidence that PPIs are the most effective agents in preventing CIB, but they may increase the risk of pneumonia. The balance of benefits and harms leaves the routine use of SUP open to question.
Link:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5770505/
CitationZhou, Xiaoyang, et al. “Stress Ulcer Prophylaxis with Proton Pump Inhibitors or Histamine 2 Receptor Antagonists in Critically Ill Adults – a Meta-Analysis of Randomized Controlled Trials with Trial Sequential Analysis.” BMC Gastroenterology, vol. 19, no. 1, 21 Nov. 2019, https://doi.org/10.1186/s12876-019-1105-y.
AbstractBackground: Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults.   Methods: Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed.   Results: Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42– 0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09).   Conclusions: SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.
Link:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873751/
CitationKrag, Mette, et al. “Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU.” New England Journal of Medicine, vol. 379, no. 23, 6 Dec. 2018, pp. 2199–2208., https://doi.org/10.1056/nejmoa1714919.
AbstractBACKGROUND Prophylaxis for gastrointestinal stress ulceration is frequently given to patients in the intensive care unit (ICU), but its risks and benefits are unclear.   METHODS In this European, multicenter, parallel-group, blinded trial, we randomly assigned adults who had been admitted to the ICU for an acute condition (i.e., an unplanned admission) and who were at risk for gastrointestinal bleeding to receive 40 mg of intravenous pantoprazole (a proton-pump inhibitor) or placebo daily during the ICU stay. The primary outcome was death by 90 days after randomization.   RESULTS A total of 3298 patients were enrolled; 1645 were randomly assigned to the pantoprazole group and 1653 to the placebo group. Data on the primary outcome were available for 3282 patients (99.5%). At 90 days, 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died (relative risk, 1.02; 95% confidence interval [CI], 0.91 to 1.13; P=0.76). During the ICU stay, at least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole and 22.6% of those assigned to placebo (relative risk, 0.96; 95% CI, 0.83 to 1.11). In the pantoprazole group, 2.5% of patients had clinically important gastrointestinal bleeding, as compared with 4.2% in the placebo group. The number of patients with infections or serious adverse reactions and the percentage of days alive without life support within 90 days were similar in the two groups.   CONCLUSIONS Among adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo. (Funded by Innovation Fund Denmark and others; SUP-ICU ClinicalTrials.gov number, NCT02467621. opens in new tab.)
Link:https://www.nejm.org/doi/full/10.1056/NEJMoa1714919

Summary of Evidence:

Author (Date)Level of EvidenceSample/Setting (# of subjects/ studies, cohort definition etc. )Outcomes StudiedKey FindingsLimitations and Biases
Vilcu, Ana-Maria, et al. (2019)Cohort StudyThere were 233,596 patients receiving PPI therapy and 626,887 matched patients not receiving PPI therapy included in the analysis.    The outcome of interest was the occurrence of at least 1 AGE episode during the epidemic period. It was coded as a binary variable (≥ 1 AGE case vs none).At least 1 acute gastroenteritis (AGE) epidemic episode was identified in 3131 patients (1.3%) receiving PPI therapy and in 4327 patients (0.7%) not receiving PPI therapy.   Patients aged 45 years and older receiving continuous PPI therapy had a significantly higher risk of developing AGE during periods of circulation of enteric viruses compared with those not using PPI therapy.   One-half of continuous PPI prescriptions are inappropriate. As regions head into enteric viral infection season, this would be the time to reassess the ongoing need for PPI therapy in patients, especially older adults, and potentially deprescribe.First, diagnoses were not available, and ascertainment of the AGE status relied solely on drug dispensing data.   Second, the actual PPI doses were unavailable, and a dose-response relationship could not be investigated.

Third, there is a risk of incomplete follow-up, which may result in misclassification of outcome or exposure status.
Orelio, Claudia C., et al. (2021)Systematic Review10 studies of adult, hospitalized patients in non-ICU settings, in which an intervention to reduce the use of inappropriate PPI was evaluated.   RCTs and comparative observational studies reported in English, Dutch, or German were eligible for inclusion.   Studies that addressed both PPI and H2RA medication as stress ulcer prophylaxis (SUP) were included if data on PPI use could be extracted separately.   Studies combining inpatient and outpatient data were included when inpatient data could be extracted separately.The primary outcome studied was inappropriate PPI prescription or use   Secondary outcomes included adverse pharmaceutical effects and healthcare use.In 2013, the Choosing Wisely campaign has identified PPI and H2RA acid-suppressive therapy for SUP as low-value care that should be avoided.   Among ten studies aimed at reducing inappropriate PPI use for SUP, all used mainly educational intervention strategies targeted at providers.   There was not an observed correlation between the effect size of inappropriate PPI use or prescription and the amount or types of de-implementation interventions in the studies.   Secondary outcomes were scarcely and inconsistently reported.None of the studies included provided sufficient intervention details to allow knowledge transfer of effective intervention strategies.
Alhazzani, Waleed, et al. (2017)Meta-analysis57 RCTs were included in this study.   18 trials compared PPIs with H2RAs; 2 PPIs with sucralfate; 4 PPIs with placebo; 18 H2RAs with sucralfate; 21 H2RAs with placebo; and 6 sucralfate with placebo.   Trial sample size ranged from 28 to 1200 patients. Different doses, routes of administration, and durations of prophylaxis were used for PPIs and H2RAs across the trialsThe primary outcome studied was the incidence of clinically important GI bleeding.   Secondary outcomes studied were incidences of pneumonia, mortality, C. difficile infections, and overt GI bleeding.PPIs ranked first in their effectiveness in preventing clinically important GI bleeds and overt GI bleeds, but dead last when compared to H2Ras and placebo in the incidence rate of developing pneumonia.   The universal use of SUP should be reconsidered in the light of uncertain net benefit.Estimates of baseline risk vary considerably across the included trials.   Only one trial addressed C. difficile infection, which is important given a recent 30,000-patient retrospective observational study suggesting that PPIs may increase the risk of Clostridium difficile colitis.   Majority of trials did not report on nutritional management, which limited the ability to examine the effect of enteral nutrition as an effect modifier.
Zhou, Xiaoyang, et al. (2019)Meta-analysis29 RCTs were included in this analysis.   Seven trials were multi-center, and twenty-two trials were single-center.   The discrepancy in the number of subjects between trials were large and it varied from 25 to 3298.Primary outcomes included clinically important and overt GI bleeding.   The secondary outcome studied was for all-cause mortalityUse of PPIs in stress ulcer prophylaxis (SUP) was associated with a reduced incident of clinically important GI bleeding and overt GI bleeding, but had no effects on the all-cause mortality   SUP was not associated with a lower mortality compared with the control group, regardless of the trials quality, the type of SUP used, and whether EN was used.   One of the included trials revealed a higher incidence of pneumonia in patients received H2RA, while other observational studies also found an increased risk of infectious complications, including pneumonia and CDI, in critically ill patients receiving SUP.There was significant statistical heterogeneity in the analysis for the overt GI bleeding,   There was also clinical heterogeneity between studies in the dosage, route of administration, and infusion duration of drug used.  
Krag, Mette, et al. (2018)RCTA total of 3298 patients were enrolled; 1645 were randomly assigned to the pantoprazole group and 1653 to the placebo group.The primary outcome was death by 90 days after randomization.   The secondary outcomes were clinically important events in the ICU (defined as clinically important gastrointestinal bleeding, new-onset pneumonia, C. difficile infection, or acute myocardial ischemiaIn predefined subgroup analyses, there was no heterogeneity in the effect of pantoprazole as compared with placebo on mortality at 90 days between patients with and patients without a history of liver disease, a history of or ongoing coagulopathy, shock, or mechanical ventilation.   A total of 360 (21.9%) of 1644 patients in the pantoprazole group and 372 (22.6%) of 1647 in the placebo group had one or more clinically important events in the ICU.   In the pantoprazole group, 41 patients (2.5%) had clinically important gastrointestinal bleeding, as compared with 69 (4.2%) in the placebo group.   In this trial of patients who were admitted to the ICU for an acute condition and were at risk for gastrointestinal bleeding, there was no significant differences between pantoprazole and placebo with regard to either 90-day mortality or the number of patients with a composite outcome of four clinically important events.  At 90 days, 510 patients (31.1%) in the pantoprazole group and 499 (30.4%) in the placebo group had died, so there was immediately a group that could not be included in follow-up.   There was not mandate diagnostic endoscopy to assess the source of bleeding and was therefore unable to differentiate between stress ulcers and other causes of gastrointestinal bleeding.

Conclusions: (Briefly summarize the conclusions of each article then provide overarching conclusion)

Article 1 (Vilcu et al.): Individuals 45 years of age and older who receive PPI therapy on a regular basis have a higher risk of getting acute gastroenteritis when enteric viruses are most prevalent. The findings of this study support the hypothesis that persistent PPI use is linked to an increased risk of infections with enteric viruses and highlight the need for additional research to confirm this link and look into the pathophysiological mechanisms. However, there are limitations related to exposure and outcome ascertainment as well as potential residual confounding.

Article 2 (Orelio et al.): Ten studies used primarily educational intervention strategies aimed at providers to decrease inappropriate PPI use for stress ulcer prophylaxis in adult hospitalized, non-ICU patients. In some studies, the number of inappropriate PPI prescriptions or uses was reduced slightly to moderately. There was no one de-implementation strategy that was found to be superior. Due to variations in study populations, settings, reported outcome measures, and combination of interventions, the studies were heterogeneous. Poor implementation and reporting design was prevalent.

Article 3 (Alhazzani et al.): PPIs have the lowest absolute risk of clinically significant GI bleeding compared to no prophylaxis, making them the most effective preventative measure for stress ulcers. However, the benefit of PPIs must be weighed against the possibility of pneumonia and Clostridium difficile infection. The best estimate of the increase in pneumonia with PPIs compared to no prophylaxis is over 3%, according to moderate-quality evidence. These figures cast doubt on SUP’s overall net benefit and widespread adoption.

Article 4 (Zhou et al.): Critically ill patients in the ICU constantly experience various hemodynamic changes, such as hypoxia and hypotension, which can reduce GI mucosal blood flow and cause a breakdown of the GI mucosa’s defense mechanisms, leading to stress-related ulcers and subsequent GI bleeding. According to this meta-analysis, using PPI or H2RA to prevent stress ulcers was linked to a lower incidence of clinically significant GI bleeding and overt GI bleeding, but had no impact on all-cause mortality, pneumonia incidence, or C. diff infections.

Article 5 (Krag et al.): The 90-day mortality, percentage of days alive without the use of life support, and number of patients experiencing clinically significant events, infectious adverse events, or serious adverse reactions were comparable between pantoprazole-treated patients and placebo-treated patients among adult ICU patients who were at risk for gastrointestinal bleeding. Clinically significant gastrointestinal bleeding in the ICU occurred less frequently in patients taking pantoprazole compared to those taking a placebo.

Weight of the Evidence – summarize the weaknesses/strengths of the articles and explain how they factored into your clinical bottom line (this may recap what you discussed in the criteria for choosing the articles)

  1. Article 3 (Alhazzani et al.): This 2018 meta-analysis included 57 trials, enrolling over 7,000 critically-ill patients looked to my question regarding the efficacy of PPIs as stress ulcer prophylaxis when compared to an array of other treatment options.

  2. Article 4 (Zhou et al.): Another meta-analysis, this study was also extremely strong, including 29 RCTs. The large difference between this article and the one above, was that this study only looked at the primary outcome of clinically important and overt GI bleeding, along with the secondary outcome of all-cause mortality. Additionally, this study only looked at patients using PPI therapy vs. placebo as opposed to other treatment options included in the study above.

  3. Article 1 (Vilcu et al.): While only a cohort study, I find this study stronger than the remaining two due to the size of the population studied. Over one year, this study analyzed data from over 800,000 patients, results that are capable of being applied to a larger, national scale.

  4. Article 5 (Krag et al.): A single RCT, this study looked at the effects of a single drug in the PPI compared to a placebo group. An additional limitation of this study was by looking at patients strictly in a critical care ICU setting, there was a slight drop (0.5%) in patients available for 90-day due to passing away.

  5. Article 2 (Orelio et al.): Although a systematic review, this study’s main focus was to compare approaches de-implementation and reducing inappropriate prescriptions. This study did not show what benefits the de-implementation had on any specific patient population, only showing why it is important to do so.

Magnitude of Effect

  1. (Vilcu et al.): At least 1 acute gastroenteritis epidemic episode was identified in 3131 patients (1.3%) receiving PPI therapy and in 4327 patients (0.7%) not receiving PPI therapy. The adjusted relative risk of AGE for those receiving PPI therapy was 1.81 (95%CI, 1.72-1.90) for all ages considered, 1.66 (95%CI, 1.54-1.80) among those aged 45 to 64 years, 2.19 (95%CI, 1.98-2.42) among those aged 65 to 74 years, and 1.98 (95%CI, 1.82-2.15) among those aged 75 years and older.

  2. (Orelio et al.): One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03–0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18–0.26 to RR 0.76; 95% CI 0.68–0.86). No significant differences in the occurrence of pharmaceutical effects (n= 1) and in length of stay (n = 3) were observed.

  3. (Alhazzani et al.): PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence).

    There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality).

  4. (Zhou et al.): SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42– 0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63)

  5. (Krag et al.): During the ICU stay, at least one clinically important event (a composite of clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) had occurred in 21.9% of patients assigned to pantoprazole and 22.6% of those assigned to placebo (relative risk, 0.96; 95% CI, 0.83 to 1.11). In the pantoprazole group, 2.5% of patients had clinically important gastrointestinal bleeding, as compared with 4.2% in the placebo group.

Clinical Bottom Line and Significance:

Given the results of these studies, it would be my clinical opinion that PPIs are the most effective prophylactic strategy for stress ulcer prophylaxis when compared to other agents or no treatment at all. However, the benefit of PPIs must be balanced against the danger of pneumonia and, perhaps, Clostridium difficile infection. When the patient is no longer at risk for stress ulceration, the prophylaxis should be stopped. However, today, there are not any standards or tools that specify when it’s okay to stop using prophylaxis. Nevertheless, unless risk factors continue, this research supports that prophylaxis should be stopped after ICU discharge. This approach is supported by the argument that, despite prophylaxis’ ability to reduce nosocomial GI bleeding among non-critically ill patients compared to no prophylaxis, these patients’ overall risk of bleeding is low. Several studies have shown a persistently high rate of ongoing SUP among patients who are discharged from the ICU, despite the lower risk in hospitalized patients who are not critically ill. As mentioned in my strongest study, there was sufficient statistical evidence that supports an increased risk of pneumonia when PPIs were compared with H2 blockers (OR 1.27, 95% CI 0.96-1.68; moderate-quality evidence), sucralfate (OR 1.65, 95% CI 1.20-2.27), and placebo (OR 1.52, 95% CI 0.95-2.42; 3.1 percent absolute increase).These figures raise fundamental doubts about the net benefit of SUP and its widespread adoption.

Journal Article and Summary

Article: Prevalence and Treatment Outcomes of Hand and Wrist Injuries in Professional Athletes: A Systematic Review

On this rotation, one of the biggest fears shared by patients was whether or not they would be able to return to their normal level of function following treatment. I chose to find a systematic review conducted through the Hospital for Special Surgery reviewing the literature on injuries of the hand and wrist in professional athletes to determine the prevalence and types of injuries sustained in professional sports, the management and clinical outcomes of such injuries, and the statistics regarding return to play. This review included 4,300 separate hand and wrist injuries across several major sports with primary outcomes of levels of management and the ability to return to play once treatment was complete. While this study found that roughly 98% of athletes were able to return to their respective sports (with healing times ranging by sport), one limitation that this study did have was they did not use statistics within each sport to determine whether the athlete was performing at a similar level as prior to the injury.

Site Evaluation Summary

Site Evaluation: Fahim Sadat, PA-C

For this rotation, I presented one worker’s compensation and one no-fault motor vehicle collision, two cases that made up a large majority of the work I did on this rotation. During our presentations, Fahim emphasized the importance of putting together a clear, concise, and detailed plan to show us how any provider who takes care of your patient after you would be able to continue care as you have outlined it. Being the second time that I have been with Fahim for an evaluation, I was able to see how my H&P’s and creating a plan have evolved since our first meeting back in February/March. One of the things that I along with two other students were challenged with during our evaluations was our ability to create an argument for any of the differential diagnoses listed. This is something that we have had practice with since our time as didactic students but bringing it into real practice stresses why it is important to use all of the tools that are at our disposal to do what is best and right for our now real patients.

Rotation Reflection

Coming into this rotation, I was excited yet unsure of what the day-to-day dealings would be as my site, CitiMed was affiliated with JFK international airport. Besides myself, there were another three students that were divided between two providers, one nurse practitioner, and one physician assistant. Each day, you were assigned to a room, and after some training, you saw and cared for patients independently before presenting the case to the provider. At this office, cases were made up almost entirely of either workers’ compensation injury cases or no-fault MVCs, with the remaining being DOT, CDL, or other pre-employment physicals. When dealing with a workers’ compensation case, this rotation stressed the importance of being able to complete a thorough comprehensive physical exam. As many of these cases will at some point end up in a courtroom, it is our notes and plans that lawyers will request to verify that injuries obtained on duty were serious enough to keep these employees out of work. Adding in that this practice would sometimes see upwards of 60 patients per day, one of my biggest takeaways from this rotation was being able to complete a quick yet efficient exam with an emphasis on all documentation.

When helping complete employment physicals, I was also able to help with some tests that are not normally covered when working on inpatient services like our other rotations. While I have completed countless EKGs prior to and during school, getting to complete audiograms, vaccine injections, and drug testing are things that I have only had exposure to while on my ambulatory care rotation earlier this year. While these tasks are not normally done by the main providers at CitiMed, working with the medical assistants, techs, and front desk staff helped the entire process run smoother for patients and confirmed that healthcare requires a team approach.

The CitiMed system also employs specialists, with teams in Pain Management, Orthopedics, Hand Surgery, Podiatry, and Physical Therapy. Once patients were initially evaluated, we as the primary provider would be able to tailor their care to include services that would serve them best. Getting to spend some additional time with the physical therapy team, I was able to see some of the additional services offered, such as shockwave stimulation therapy, acupuncture, EMG to diagnose radiculopathies, and hyperbaric oxygen therapy.

While this rotation did show me many different aspects of family medicine, I believe this site would be great for students who aspire to go into orthopedics. Being able to accurately use a goniometer to document a patient’s range of motion and understand all conservative management measures such as home exercise programs, epidural spinal injections, and nerve branch blocks prior to stepping up to surgical management, is essential for seeing patients through their injuries from start to finish.

History and Physical – Rotation 6

Identifying Data

July 14th, 2022 – 10:45AM
GG, 36F, African American, Queens, NY
Informant: Patient, reliable
Referral Source: Self

Chief Complaint: “I have had right hand/wrist pain x4 week”

History of Present Illness:

36-year-old female with a past medical history of sickle cell trait presents to CitiMed JFK for evaluation for injury on duty of her right wrist and hand sustained 6/10/22. The patient works for Jet Blue as a baggage handler, and as she was grabbing luggage from the belt loader with her left hand, she accidentally hit her right hand as she threw the luggage into the plane. The patient states she was in immediate pain and but completed loading for the current flight. The patient states she reported the injury to her supervisor and was referred to this facility. Without completing her shift, she drove herself to this clinic for further evaluation and treatment. She denies any LOC, head trauma or any open wounds.

Today her right hand and wrist pain is rated 6/10, constant, throbbing, and worse with movement and gripping. She admits to pain radiating from the wrist to the interphalangeal joint of the thumb. Also admits to numbness and tingling at the thenar eminence as well as the lateral aspect of her right thumb. She reports using a splint with mild relief and takes one 500mg Tylenol Extra Strength twice daily with relief. She was evaluated by the facility’s affiliated hand surgeon on 6/24/22, who gave her a splint to be worn at all times and placed her on a prednisone taper, which she had completed. She was seen again on 7/6/22 and was given a steroid injection but reported increased pain and swelling. She is currently utilizing physical therapy 3 times per week. She currently denies headaches, vision changes, neck pain, chest pain, n/v/d, fever, and abdominal pain.

Past Medical History:

  • Sickle cell trait

Past Surgical History:

  • Denies

Medications:

  • Tylenol Extra Strength 500mg, PO PRN

Allergies:

  • Strawberries: swollen tongue
  • NKDA

Family History:

  • Father: Alive, unknown medical history
  • Mother: Alive, unknown medical history
  • Sister: Alive, unknown medical history

Social History:

  • Diet: Does not follow any specific dietary regimen
  • Home: Lives at home with her boyfriend.
  • Smoking: Denies current or past use of cigarettes, e-cigarettes, or other tobacco products
  • Alcohol: Admits to socially drinking alcohol once per week.
  • Drugs: Denies use of any illicit drugs.
  • Exercise: Admits to going to workout classes three times per week prior to injury
  • Sleep: Sleeps 7-8 hours per night, using 2 pillows.
  • Travel: Denies any recent travel

Review of Systems:

General: Denies any recent weight loss or gain, loss of appetite, generalized weakness or fatigue, night sweats, fever, or chills

Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.

Head: Denies headaches, migraines, vertigo, nausea, or vomiting.

Eyes: Positive corrected vision. Denies photophobia, double vision, blurry vision, excess tearing or dryness, or pruritis. Last eye exam in April 2022.

Ears: Denies hearing loss, tinnitus, vertigo, discharge, earache.

Nose and sinuses: Denies discharge, obstruction, allergies, or epistaxis

Mouth and throat: Denies sore throat. Denies bleeding gums, ulcerations. Does not wear dentures. Last dental exam in May 2021.

Neck: Denies stiffness or decreased range of motion. Denies localized swelling, or lumps.

Pulmonary: Denies shortness of breath, wheezing, or productive cough. Denies hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.

Cardiovascular: Denies chest pain, palpitations, edema, irregular rhythms.

Gastrointestinal: Has no change in bowel habits, with no changes in color or consistency. Denies changes in appetite, intolerance to any foods, no nausea/vomiting/dysphagia, pyrosis. No constipation, bleeding, (hemorrhoids, melena, or hematochezia), or abdominal pain.

Genitourinary: Menarche at 12.  LMP 7/3/22. Regular, 28 days cycle. Denies dysmenorrhea. Denies incontinence, dysuria, nocturia, urgency, oliguria, or polyuria. Denies any history of STDs.

Nervous: Denies headaches, seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness.

Musculoskeletal: See HPI. Denies other joint pain, swelling, weakness, and changes in range of motion in other extremities.

Peripheral Vascular: Denies peripheral edema. Denies intermittent claudication.

Hematologic: Denies history of DVT/PE or previous blood transfusions.

Endocrine: Denies heat/cold intolerance, excessive sweating.

Psychiatric: Denies history of depression and anxiety. Denies having SI/HI or previously seeing a mental health professional.

Physical Exam:

General: 36F, A&O x3, sitting on exam table, wearing an Ace splint on her right wrist, in no acute distress. She is well groomed and well-developed for age. She does not appear ill.

Vitals:

  • BP(Seated): R – 123/76
  • P: 62, regular
  • R: 16breaths/min, unlabored
  • T: 98.6F (37.0C), oral
  • O2 Sat: 99% on room air
  • Height: 64 inches – Weight: 137lbs – BMI: 23.5 – Normal  

Skin: Warm and moist with good turgor throughout. Nonicteric. No lower extremity erythema and warmth. Nontender on palpation. No cyanosis or jaundice.

Hair: Average quantity and distribution.

Nails: No clubbing, capillary refill <2 seconds in all four extremities

Head: Normocephalic, atraumatic, nontender to palpation throughout.

Eyes: Symmetrical OU. No strabismus, exophthalmos, sclera white, cornea clear, conjunctiva pink.

  • Visual corrected – 20/20 OS, 20/20 OD, 20/20 OU from 6feet with pocket Snellen
  • Visual fields full OU.  PERRLA, EOMs intact with no nystagmus 
  • Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, or exudates

Ears: Symmetrical and appropriate in size. No masses, lesions, or deformities on external ears.  No discharge or foreign bodies in external auditory canals AU. TM’s white and intact with light reflex in good position AU. 

Mouth:

  • Lips: Pink and moist with no lesions
  • Mucosa: Pink with no masses or lesions. Non-tender to palpation. No leukoplakia.
  • Palate: Intact with no masses or lesions Non-tender to palpation; continuity intact. 
  • Teeth: Good dentition with no obvious dental caries noted.
  • Gingivae: Pink. No hyperplasia; masses; lesions; erythema or discharge.
  • Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.
  • Oropharynx: Well hydrated, no masses, lesions, or foreign bodies. Grade 1 tonsils, class II Mallampati score. Uvula pink, no edema

Neck: Trachea midline. 2+ Carotid pulses, no stridor, thrills, or bruits noted bilaterally.

Thyroid: Nontender to palpation, no masses, no bruits noted. No thyromegaly.

Chest: Symmetrical, no deformities or trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.

Lungs: Clear to auscultation and percussion bilaterally.   Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart: Carotid pulses are 2+ bilaterally without bruits. RRR, S1 and S2 are distinct with no murmurs, S3 or S4. PMI in 5th ICS in mid-clavicular line.

Abdomen: Abdomen is symmetric with striae, no pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac/femoral bruits. Non-tender to light palpation, tender on deep palpation in epigastric and suprapubic regions. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated

Neurologic:

  • Mental Status: Alert and oriented to person, place, and time. Receptive and expressive abilities intact. Thought coherent, no dysarthria, dysphonia, or aphasia. Memory and attention intact excluding during episode.

  • CN II-XII grossly intact.

  • Motor/Cerebellar: Full active ROM of all extremities without rigidity or spasticity. No atrophy, tics, tremors, or fasciculation.

  • Reflexes:
 RL RL
Brachioradialis2+2+Patellar2+2+
Triceps2+2+Achilles2+2+
Biceps2+2+BabinskiAbsentAbsent
Abdominal2+/2+2+/2+ClonusNegative
  • Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, no edema present. Pulses are 2+ bilaterally in upper and lower extremities.

Musculoskeletal:

Right hand and right wrist: mild edema over thenar eminence and over thumb joint. No ecchymosis, erythema, open wounds or deformity. Mild tenderness over wrist joint, thenar eminence, and thumb joint. No tenderness over anatomical snuffbox.

Decreased ROM of wrist due to pain. Dorsiflexion 50/70, palmar flexion 60/60 with mild pain, ulnar flexion 30/30 and radial flexion 20/20. Thumb flexion 20/60. Mild numbness over thenar eminence and tingling that radiates up ulnar side of arm. Sensation intact. Able to move all digits with hesitance and pain upon moving first digit.

Full active ROM of all extremities. Bilateral shoulder height symmetrical. No obvious deformities.

Strength 4/5 in right upper extremity and 5/5 left upper and both lower extremities.

Grip 3/5 right and 5/5 left.

Available Imaging:

  • MRI right wrist (6/17/20): minimal joint effusion, no acute fracture or dislocation.

  • MRI right hand (6/17/20): findings consistent with partial tear of ulnar collateral ligament. Soft tissue swelling over the dorsal aspect of the 1st interspace. No evidence of acute fracture or dislocation.

Assessment:

GG is a 36-year-old female denying past medical history who presents to our office for a right wrist injury while on duty.

Plan:

#Partial tear of right ULC

  • Not fit for duty.
  • Hand surgeon f/u in August.
  • OTC Tylenol as needed for pain, ice, Bengay over the affected region.
  • PT 2-3x week.
  • Continue using splint.
  • F/u in 2 weeks or earlier if needed. ED for worsening symptoms.

Journal Article and Summary

The article that I chose was titled ‘Effectiveness of an Evidence-Based Amputee Rehabilitation Program.’ The study had the aim of understanding how a tailored therapy program can improve prosthetic weight-bearing, musculoskeletal endurance, walking speed, and even 1-year survival rate. It was a randomized cohort trial done with the Miami VA and University of Miami School of Medicine.

They did the research because a 2013 review of VA services including almost 13,000 veterans  found that only 55% received rehabilitation postoperatively. And of those who did, many were not rehabilitated to their full potential level of function as they were still deemed a high risk for falls at discharge. Because of the importance of postamputation PT, there was a need for the development of a rehabilitation program that targets impairments and limitations specific to amputees.

The Amputee Mobility Predictor is a quick and easily administered assessment tool designed to measure the functional status of amputees with and without the use of a prosthesis (AMPPro and AMPnoPro, respectively). Each AMP task is designed to assess a person’s ability to perform specific physical skills at the activity level (general tasks/demands and mobility); in addition, each AMP task is also comprised of a number of components (neuromusculoskeletal and movement-related functions) within the body such as bed-to-chair transfers, rising from a chair, foot clearance, and step length. From here limitations are identified and specific exercises are prescribed to address those deficits.

The primary purpose of this study was to determine if an evidence-based amputee rehabilitation program will improve the functional mobility of people with unilateral amputation who have previously completed a traditional prosthetic rehabilitation program.

Two research physical therapists assumed different roles and were blinded from each other throughout the study. One physical therapist who administered the AMPPro, AMPnoPro, and 6MWT at baseline and at the end of the 8-week intervention was blinded to group assignment (intervention vs wait-list control) and all intervention data. At the conclusion of baseline testing, participants were randomly assigned to either the 8-week intervention or wait-list control for 8 weeks. The other physical therapist implemented the EBAR program for all participants. The EBAR program was administered for 60 minutes, 3 times per week for 8 weeks. The AMP and 6-MWT were also administered at the conclusion of weeks 2, 4, and 6 to assess change in function and modify the exercise prescription as outlined in the EBAR program

The EBAR program consisted of 5 primary components: (1) cardiopulmonary endurance and flexibility, (2) trunk and lower limb strengthening, (3) balance and coordination, (4) weight-bearing and stance control, and (5) prosthetic gait training

The mean age was 63.25 years, mean time since amputation was 8.1 years, 81.2% were male, and 75% lost their limb because of peripheral vascular disease or diabetes mellitus.

The intervention group’s mean AMPPro score increased from 36.4 to 41.7 while the wait-list control group’s score remained unchanged from 35.3 to 35.6 (P = .004). Similarly, the AMPnoPro mean score of the intervention group improved from 23.2 to 27.1, while the wait-list control group score also remained unchanged (24.7 to 25.0; P = .04). The 6MWT distance of the intervention group improved from a mean of 313.6 m to 387.7 m (P = .04), while the wait-list control group again demonstrated virtually no change (262.6 m to 268.8 m)

Even though the participants enrolled in this study were many years postamputation and post-rehabilitation, those who received the 8-week EBAR program demonstrated clinically significant improvement in mobility as measured by the AMPPro, AMPnoPro, and 6MWT.

One of the biggest limitations to this study was the sample size. They approached 326 candidates, of which 306 were unable to declined to participate. In my research I found an older systematic review from 2016 that looked at 8 RCTs and they all only ranged from 4 to 60 participants. So obviously, there is a need for intervention research with larger populations.

Some of the questions I still had from the study include when is best time after amputation surgery to administer specific exercises, what is the appropriate duration for physical therapy, and how do we know when a patient has reached their maximum potential? Should this therapy wait until basic movements such as sitting balanced and transferring have become easy for the patient?

Future EBAR research should include a multi-site study at Veteran Affairs facilities and private sector hospitals that care for people with LLA

Site Evaluation Summary

Site Evaluator: Emily Davidson, PA-C, DC

For this rotation, both of my evaluations were conducted via Zoom with Professor Davidson. I enjoyed having Professor Davidson as my evaluator this time around because while we did have her for our Interviewing and Counseling course almost two years ago, we were completely remote at that time so this was the first time that my class is really getting to work with her regarding patient care. During our evaluations, she made sure to address all of my concerns regarding the site and rotation as a whole. Before presenting patients, we reviewed my pharm cards in which she really wanted to see that we were grasping the information regarding why we would give a medication as opposed to saying we use a particular class for a particular ailment. Once of the things I appreciated was her tips for studying drugs in the future, especially for our boards, specifically, not wasting our time writing down extra information that we may already know. She also challenged me to pick drugs that may be a little more challenging to broaden my understanding of some of the tougher concepts.

For the first evaluation, I presented a patient who was admitted for restorative therapy falling a fall at home. During my presentation, Dr. Davidson brought-up a lot of helpful points into making my HPI and physical exam stronger for the future. While the overall structure was there, she tasked me with keeping my chronological sequence fluid to understand the patient’s previous status and what has changed in terms of ADL assistance need. She also made sure to specify that once the HPI addresses everything up to the point of admission, my assessment and plan should address every problem brought up in my HPI.

For the second evaluation, I presented a patient who was admitted for therapy following an above the knee amputation along with a journal article that showed the significance of an evidence-based amputee rehabilitation program. This case was much smoother than the first as I took all of Dr. Davidson’s recommendations and found ways to improve the overall flow of my writing and oral presentation.

Because of the input given, these evaluations were undoubtedly some of the most beneficial of all my rotations. I’ll be able to apply the evaluations’ recommendations to the balance of my rotations and my professional practice.

Rotation Reflection

As the remaining non-PAEA core rotation, I was not entirely sure what to expect coming into my Long-Term Care rotation. Completed at Gouverneur, a skilled nursing facility that is a part of the NYC Health and Hospitals, I was exposed to a large variety of patients that had vastly different goals of care. Because the facility is split as a subacute rehab and long-term nursing home, my days each week were split in an effort to understand how the providers plan has to change to tailor to patient goals.

On the subacute rehab floors, these patients were often transferred from local hospitals to for restorative therapy, which when completed, they could return home and assume the independent ADLs. My main preceptor on these days, was Dr. Polina Gilchyonok, the chief of subacute service. With her, we would attend morning report with the charge nurses of each floor to review any patient issues that had come up in the last 24 hours. These meetings were also attended by social work, physical therapy, wound care, and dietary to show the wholistic approach that the facility took to each patient. After receiving my assigned patients for the day, I would head to the floors to meet with nursing to see these patients together and address any issues that the patients felt needed discussion. These interim medical visits gave me the opportunity to work on my patient education and counseling for lifestyle changes once they left our facility. On these days, I could also work with the nursing staff directly to get hands-on skills training including inserting a straight catheter and performing blood draws. After seeing patients, I would write-up my interim visit notes to be reviewed along with reviewing the medications that the patient came in prescribed with from the hospital. Because I was given so much independence when it came to seeing patients, I used this rotation as an opportunity to refine some of my skills of completing a full physical exam as we learned during the didactic year. Coming from the emergency room where the physical exam is often tailored to the chief complaint, having this time proved most useful.

The remaining days each week were spent under the chief medical officer of the facility, Dr. Sherry Humphrey, a geriatric medicine specialist on the long-term floors. On these floors, patients, also called residents on these floors, are only required to be seen and have medications reviewed by a physician or NP once a month, unless otherwise needed. Because there are roughly 300 long-term beds in this facility, I received ample opportunity to learn and refine my geriatric assessment. One area of training that I had never received before came from CPAC, the Center to Advance Palliative Care. Because so many of the long-term residents had impaired cognition or an extensive list of comorbidities, it was imperative to have organized and updated advanced directives for each resident on file. One of the toughest aspects of this rotation, in my opinion, is starting the conversation with patients and their families as to what they would like to have happen in a worst-case scenario. For some, they were ready to have that conversation, but others found it very difficult to come to acceptance with some of the matters being discussed. With many years of experience in this field, Dr. Humphrey would coach me privately on how to address questions, comments, and concerns patients may have as well as how to properly respond when the conversation becomes difficult. While we talked a lot about advanced directives throughout our didactic coursework, it is challenging when that conversation is now with a real, ill patient and not a case scenario in a group discussion. Overall, I think this rotation, and site was a great learning experience with plenty of autonomy and a staff that was always willing to help. It was great to see the interdisciplinary approach that echoed the notion that healthcare takes a team.